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Comprehensive External Assessment of Proficiency of Malaria
Microscopists and Laboratory Capacity in Districts Stratified for
Malaria Elimination in Ethiopia
Ethiopian Public Health Institute (EPHI)
&
IFCC Foundation for Emerging Nations (FEN)
March 2019
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Principal Investigator:
Desalegn Nega(MSc)1
Mobile: +251911606818;
E-mail:[email protected]
Co-Investigators:
AdugnaAbera (MSc)1,BokretsionGidey (MSc)1, AbinetAbebe (MSc)1, Abeba G/Tsadik
(MSc)1,,SindewMekasha (MSc)1, EyasuTigabu (PhD)1, AdugnaWoyessa (PhD)1, GeremewTasew
(PhD)1.
Affiliation:
1Malaria and Neglected Tropical Diseases Research Team, EPHI. POBOX 1242
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ACKNOWLEDGMENT
I would like to acknowledge the Ethiopian Public health institute (EPHI) and IFCC Foundation for
Emerging Nations (FEN) for financial support to conduct this study.
My heartfelt appreciation goes to all individual personnel who technically contributed in this
assessment.
Extraordinary recognition is afforded to Adugna Abera, Bokretsion Gidey, Abnet Abebe, Abeba
G/Tsadik, Sindew Mekasha, Dr Eyasu Tigabu, Dr. Adugna Woyessa, and Dr Geremew Tasew for
providing their technical support in protocol preparation, data collection, supervision or report write
up.
I offer my sincere gratitude to all regional health bureaus, zonal health departments, district health
offices, and public/private health facilities for their managerial supports.
Lastly but not least, my genuine appreciation goes to all local guides in helping the field survey and
the malaria microscopists for their voluntariness to participate in the survey.
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EXECUTIVE SUMMARY
Background: Successful malaria elimination calls for rapid and accurate tracking of cases so that
the personnel can promptly be treated before the occurrence of transmission. Hence, this study
assessed the competency of malaria microscopists working in health facilities.
Method: A cross-sectional study was conducted from February to June 2018 in 20 malaria
elimination targeted districts from six regional states in Ethiopia. A maximum of 5 malaria-
microscopists per each facility, available in the facility during the study period, were conveniently
included in the study. Structured questionnaires used for personal and facility interview, and 10
Giemsa stained malaria slide panels were administered to each study participant for the
performance assessment on malaria microscopy.
Result: In this assessment, 17 district hospitals, 71 health centers (HCs) and 18 private clinics
(PCs) were included. Of the 18 PCs, only 10(55.6%) had license & registration certificate. Of the
facilities, 91.5%(97/106) use light microscopy, 2.83%(3/106) use RDTs and 2.9%(3/106) use both
microscopy and RDT to detect malaria. Accessible and appropriate storage of Giemsa was
reported by 58.8%(10/17) hospitals, 81.7%(58/71) HCs & 72.2%(13/18) PCs. In 84.6%(11)
hospitals, 35.7%(25) HCs & 26.7%(4) PCs, the laboratories comply fully with the national quality
assurance guidelines. Results were recorded legibly in logbooks of 87.5%(14) hospitals, 87.1%(61)
HCs, and 87.2%(75) PCs. Technical manuals and laboratory bench aids were observed in
56.2%(9) hospitals, 57.1% (40) HCs, and 35.3%(6) PCs. Of 1896 malaria positive & 474 negative
slides administered to 237 participants, 318 slides reported falsely negative (false negativity rate:
42.7%) & 47 reported falsely positive (false positivity rate: 2.9%). The participants achieved “good”
grade [Agreement(A): 84.6%, Kappa(K): 0.6] on parasite detection and “Poor” agreement (A:
43.8%; K: 0.11) on species Identification. The agreement is lower in PCs (Detection A: 77.8%;
Identification A: 37.2%), followed by HCs (Detection A: 84.14%; Identification A: 41.64%) and
hospitals (Detection A: 86.7%; Identification A: 48.1%). No or slight agreement seen on
differentiation of P. falciparum from other species (A: 28.41%; K:0.29). Above 95% of participants,
(201/237), did not count or used only plus system of parasite count which is unacceptable per the
current WHO guideline.
Conclusion: The low competency of malaria microscopists particularly in species identification &
poor to moderate capacity laboratories in the current study place a great obstacle in front of malaria
elimination path. Therefore, Federal Ministry of Health (FMoH) in collaboration with partners is
supposed to provide comprehensive In-service training of professionals with fulfillment of laboratory
needs to have gold standard malaria microscopy service in the country.
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Table of Contents
ACKNOWLEDGMENT .................................................................................................................................... II
EXECUTIVE SUMMARY ................................................................................................................................ III
TABLE OF CONTENTS ................................................................................................................................ IV
FIGURE ........................................................................................................................................................... V
TABLES .......................................................................................................................................................... V
ABBREVIATION ............................................................................................................................................ VI
INTRODUCTION .............................................................................................................................................. 1
STUDY OBJECTIVES: .................................................................................................................................... 3
GENERAL OBJECTIVE: ..................................................................................................................................... 3
SPECIFIC OBJECTIVES: .................................................................................................................................... 3
MATERIALS AND METHODS ........................................................................................................................ 4
STUDY AREA & PERIOD ................................................................................................................................... 4
STUDY DESIGN: .............................................................................................................................................. 5
STUDY SUBJECTS: .......................................................................................................................................... 5
EXCLUSION CRITERIA: ..................................................................................................................................... 5
SAMPLE SIZE DETERMINATION ......................................................................................................................... 5
SAMPLING TECHNIQUE .................................................................................................................................... 5
DATA COLLECTION PROCESS ........................................................................................................................... 5
STUDY QUESTIONNAIRES ................................................................................................................................ 6
STATISTICAL ANALYSIS .................................................................................................................................... 6
ETHICAL CONSIDERATION ............................................................................................................................... 6
RESULT OF STUDY ........................................................................................................................................ 7
PART 1: PROFICIENCY TESTING OF MALARIA MICROSCOPISTS .......................................................... 7
Socio-characteristics of the study participants ......................................................................................... 7
Overall Performance of Malaria Microscopists ........................................................................................ 7
Detailed Description of Performance by 2x2 Tables ................................................................................ 8
PART 2: LABORATORY REAGENTS/SUPPLIES, EQUIPMENTS & DOCUMENTATION ....................... 12
Generanl Laboratory or facility Information ............................................................................................ 12
Laboratory Documentation ..................................................................................................................... 13
Laboratory Procedures ........................................................................................................................... 14
Laboratory set up ................................................................................................................................... 14
Laboratory Supplies and Equipment over the last six months prior to data collection I ........................ 15
CONCLUSION ............................................................................................................................................... 17
RECOMMENDATIONS .................................................................................................................................. 18
DISSEMINATION OF RESULTS ................................................................................................................... 18
REFERENCES ............................................................................................................................................... 18
ANNEXES ...................................................................................................................................................... 21
ANNEX 1: GENERAL QUESTIONS FOR MALARIA MICROSCOPISTS .................................................. 21
ANNEX 2: FACILITY INFORMATION QUESTIONNAIRE ......................................................................... 23
ANNEX 3: OPERATIONAL DEFINITIONS ................................................................................................. 30
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ASSURANCE OF THE PRINCIPAL INVESTIGATOR: ................................................................................ 30
SIGNATURE OF CO-INVESTIGATORS ....................................................................................................... 30
COMMENT AND CONCURRENCE OF THE RESPONSIBLE HEAD FOR PRINCIPAL INVESTIGATOR.31
FIGURE Figure 1: Malaria risk map of districts by annual parasite incidence, Ethiopia (Source FMOH NSP:
2017-2020). .................................................................................................................................. 4
TABLES Table 1: Strata of malaria elimination planned districts .................................................................. 5
Table 2: Malaria slide panels for examing study partciparts .......................................................... 6
Table 3: Socio Demographic Characteristic of malaria microscopists in Ethiopia (n=238) ............. 7
Table 4: Overall performance of malaria microscopists in terms of parasite detection and species
identification (n=237). .................................................................................................................... 8
Table 5: Parasite Detection as Positive or Negative on a 2x2 Table Format ................................. 8
Table 6: The accuracy of the differentiation of Plasmodium species (2x2 table) ............................ 9
Table 7: The accuracy of the differentiation of P. falciparum from other species (2x2 table)......... 9
Table 8: Parasite count system used by laboratory professionals ............................................... 10
Table 9: Performance of malaria microscopists on species identification with different parasite
densities (n=237). ....................................................................................................................... 11
Table 10: Overall performance of malaria microscopists against sociodemography .................... 11
Table 11: General laboratory information I. ................................................................................. 12
Table 12: General laboratory information II. ................................................................................ 13
Table 13: Laboratory Guidelines, SOPs and Manuals ................................................................. 14
Table 14: Laboratory Procedures ................................................................................................ 14
Table 15: Laboratory set up and working environment ................................................................ 15
Table 16: Laboratory Supplies and Equipment over the last six months prior to data collection I. 16
Table 17: Laboratory Supplies and Equipment over the last six months prior to data collection .. 17
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ABBREVIATION
A: Agreement
AIDS: Acquired Immuno-Deficiency Syndrome
API:Annual parasite incidence
EPHI: Ethiopian Public Health Institute
EQA: External Quality Assurance
FMoH: Federal Ministry of Health
HCs: Health Centres
HFs: Health Facilities
K: Kappa
NSP: National Strategic Plan
PCR: Polymerase Chain Reaction
PCs: Private Clinics
PHEM: Public Health Emergency Management
RDT: Rapid Diagnostic Tests
SOP: Standard Operating Procedures
WBCs: White Blood Cells
WHO: World Health Organization
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INTRODUCTION
There are different malaria diagnostic methods for case management; the common and routine
ones are patient‘s clinical assessment, microscopic examination of blood slides and the use of
rapid diagnostic tests (RDTs). The detection of Plasmodium parasites by light microscopy is yet
the primary method of malaria diagnosis in most health care facilities throughout the world [1,2]. It
has long been the method of choice for the diagnosis of many parasitic diseases, and is the gold
standard tool for routine malaria diagnosis still now. However, microscopy requires technical skills,
equipments, reagents and an electric power supply [2–5].
Lack of qualified professionals in malaria diagnosis and the lack of regular quality control
approaches in the laboratory diagnostic process have been identified as the main reasons for the
lack of success in the current strategy to control malaria [6]. Many patients are being managed as
malaria cases in spite of negative blood film result, which is due to over suspiciousness of health
workers or the perceived poor quality of laboratory findings[7]. Low performance of professionals
in microscopic diagnosis of malaria is a great challenge, which leads to inappropriate and/or
delayed treatment, emergence of drug resistance, development of serious complications up to the
death of patients. In practice, poor microscopy is a function of multiple factors, including insufficient
training and skill maintenance, slide preparation techniques, workload, condition of the microscope,
and quality of essential laboratory supplies [8].
Besides the problems associated with the poor performance of professionals in diagnosis and poor
capacity of laboratory are also great challenges in providing quality service. Major challenges in
laboratory capacity include poor physical infrastructure and inadequate supplies such as
equipments and reagents, limited human capacity, lack of clear laboratory policies and strategic
plans, and limited synergies between clinical and laboratory services [9,10]. Strong laboratory
capacity with full equipments, reagents and competent professionals ensures better curative
interventions and influences treatment-seeking behavior by attracting higher patient-flow than
facilities with a weak laboratory service [11].
Ethiopia scaled up diagnostic testing for malaria at all levels of the public health sectors:
multispecies RDTs are used at community-level in health posts and malaria microscopy is carried
out at district-level health centers as well as district, zonal and regional-level hospitals [12]. Early
diagnosis and a prompt treatment are the key strategies for the management of malaria to reduce
mortality and morbidity in Ethiopia [2,13,14].
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The main goals of the current malaria National Strategic Plan (NSP) 2014-2020 Ethiopia [15] are:
i) to achieve near zero malaria deaths (no more than 1 confirmed malaria death per 100,000
population at risk) in Ethiopia by 2020; ii) to reduce malaria cases by 75% from baseline of 2013
by 2020; iii) to eliminate malaria in selected low transmission areas by 2020. To achieve these
goals, the country must implement policies and practices that improve the quality of confirmatory
laboratory diagnosis of malaria. Improved quality in laboratory diagnosis of malaria will retain the
confidence of clinicians in laboratory results, leading to improved case management. For
successful malaria elimination, rapid and accurate management of cases is critical so that
personnel can promptly be treated before transmission occurs.
Except limited pocket studies, a comprehensive assessment of the proficiency of malaria
microscopists and laboratory capacity in terms of equipments, reagents and laboratory setup has
never been done in Ethiopia. High quality malaria diagnostics is acknowledged as a crucial element
of successful malaria elimination [16,17], with microscopy as the gold standard playing a key role
[18,19]. Experience from malaria-free countries has demonstrated the importance of well-
established, widespread, high quality malaria diagnosis, high capacity for active case follow-up and
a robust monitoring and evaluation system [20–22].
Furthermore, extensive experience from countries striving to eliminate malaria in Africa [23–25],
Asia-Pacific [26,27] and Peru in South America [28] have shown the necessity of access to reliable
and effective diagnosis with microscopy which rests upon the basis of highly trained, well-
supervised laboratory technicians who have functioning microscopes, access to re-supply of
reagents, respect for positive and negative diagnosis and constant access to anti-malarials if
malaria transmission is to be interrupted. Therefore, one of the most important approaches for
quality assurance of malaria diagnosis is regular proficiency testing of microscopists and
assessments of gaps and shortages in laboratory capacity in terms of equipments, reagents,
supplies and even the lab set up. Hence, this study was conducted with the aim of assessing
informations on the skill of malaria microscopists, and laboratory capacityin malaria elimination
planned districts of Ethiopia.
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STUDY OBJECTIVES:
General objective:
The overall objective of the study was to evaluate the professional skill of malaria microscopists,
and to assess laboratory capacity in terms of reagents, supplies, equipments and lab setup in
malaria elimination-planned districts of Ethiopia.
Specific objectives were:
To evaluate proficiency of malaria microscopists in diagnosing malaria in the facilities,
compared to expert microscopists in terms of sensitivity, specificity, agreement and
accuracy;
To assess the capacity of laboratories in terms of equipments, reagents and the setups;
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MATERIALS AND METHODS
Study area & period
This study was conducted from February to June 2018 in Dire Dawa, Harari, Oromia, Tigray and
SNNPR regions targeted for malaria elimination in Ethiopia. Ethiopia currently launched malaria
elimination in selected districts with low malaria transmission (yellow colored).
Figure 1: Malaria risk map of districts by annual parasite incidence, Ethiopia (Source FMOH NSP: 2017-2020).
The current malaria National Strategic Plan (NSP: 2017–2020) has stratified the country’s malaria
situation on the basis of transmission intensity (Annual parasite incidence; API) per 1000 population
at risk based on data from public health emergency management (PHEM) and complemented by
micro-planning data (Table 1).
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Table 11: Strata of malaria elimination planned districts
Region # of Zone # of districts Low (API<5)
Moderate (API≥5 - <100)
High (API>100)
Free (API=0)
Tigray 4 34 12 17 1 4 Amhara 3 58 43 19 0 3 Oromia 3 68 47 13 0 2 SNNP 6 77 32 39 1 0 Harari 1 1 1 0 0 0
Dire Dawa 1 1 1 0 0 0
Total 18 239 136 88 2 9
From the above table, 239 districts, including 138 low transmission strata, 90 moderate strata, 2 high transmission strata and 9 free zones, are targets for malaria elimination.
Study design:
A descriptive cross-sectional study design was used. The health centers, hospitals and private
clinics were selected conveniently from the malaria elimination targeted districts reporting
substantial malaria. Twenty districts reporting substantial malaria cases were selected from among
the 239 malaria elimination targeted districts in the country.
Study subjects:
Malaria microscopists available at the diagnostic facilities during the data collection period were
included.
Exclusion criteria:
Professionals on leave due to sickness & maternal cases, and the non-consenting ones were
excluded from study.
Sample size determination
A maximum of up to five malaria-microscopists per each facility, available in the facility during the
study period, were conveniently included in the study.
Sampling technique
Convenient sampling method was used until we had enrolled the eligible professionals in each
laboratory.
Data collection process
Based on the recommendation of WHO [2,4,5], totally 10 Giemsa-stained malaria slide panels,
were administered to study participants for the performance assessment on parasite detection,
species identification & quantification. Ten minutes per slide was allocated to each participant to
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examine the blood smear slides. Standardized malaria slide panels were distributed as the
following (Table 2):
Table 22: Malaria slide panels for examing study partciparts
S.N Composition of BF slides (Species) Number/s of BF slides Parasites Densities
01 P.falciparum of low densities 2 343
1817
02 P.falciparum of high densities 1 66,973
03 P.vivax of low densities 1 1,390
04 P.vivax of high densities 1 49,372
05 Mixed (P f+ Pv) of low densities 1 20,711
06 Mixed (P f+ Pv) of high densities 1 89,500
07 BF slide with Borellia Species 1 Not applicable
08 Negative BF Slides 2 Not applicable
Total 10
Study Questionnaires
Structured questionnaires including information on the participating facilities, laboratory capacity
(equipments, reagents, lab setup) and socio-demography of professionals were distributed to
collect data.
Statistical analysis
Data was entered into & analyzed using statistical packages for windows (SPSS 20 & STATA 14).
Based on the calculation, the strength of agreement between participants and expert readers was
classified as : kappa<20% as slight agreement, >20%– 40% as fair agreement, >41%–60%
moderate agreement, >61%–80% substantial agreement, >81%–99% almost perfect agreement
[29,30].
Ethical Consideration
The research proposal was approved by the Directorate of Bacterial, Parasitic and Zoonotic
Diseases Research; and then ethically cleared by the Scientific and Ethical Review Committee
(SERO) of the Ethiopian Public Health Institute (EPHI). Official cooperation letters were written by
the EPHI to the participating facilities. Consent forms were used to take the agreement of
participating health professionals. To ensure confidentiality, the participants’ data were linked to a
specific code number only.
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RESULT OF STUDY
Part 1: PROFICIENCY TESTING OF MALARIA MICROSCOPISTS
Socio-characteristics of the study participants
The mean age of the study participants was 28.9 years (Range: 20-52 years). Most of the
participants were in the age group of 20–30 years. Those who held diploma certificate accounted
for 68.1%, bachelor degree 31.5%, and master degree 0.4%. Most participants, those accounting
62.2%, were graduates from government college. Around 40% of participants did not have
refresher training on malaria microscopy within 2 years prior to study commencement (Table 3).
Table 33: Socio Demographic Characteristic of malaria microscopists in Ethiopia (n=238)
Characteristic Frequency
Percent (%)
Age(Years) 20 - 30 179 75.2
31 - 40 51 21.4
≥41 8 3.4
Sex Male 150 63.0
Female 88 37.0
Type of college Government 148 62.2
Private 90 37.8
Level of Education Diploma 162 68.1
BSc 75 31.5
MSc 1 0.4
Work Experience (in Years)
< 2 39 18.3
2-5 66 31.0
>5 108 50.7
In-service Training with the past 2 yrs
Trained 140 59.6
Not trained 95 40.4
Training Provided by
Government 114 82.0
Partners 25 18.0
Place of Work Public (Government) 217 91.2
Private 21 8.8
Overall Performance of Malaria Microscopists
For this competency assessment, the WHO guideline (Malaria microscopy quality assurance
manual version 2) for grading the performance of parasite detection and species identification was
used [31]. Of 1896 malaria positive & 474 negative slides administered to 237 participants, 318
slides reported falsely negative (false negativity rate: 42.7%) & 47 reported falsely positive (false
positivity rate: 2.9%) (Table 4 & 5).
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Referring to expert readers, the participants achieved “good” grade [Agreement(A): 84.6%,
Kappa(K): 0.6] on parasite detection and “Poor” agreement (A: 43.8%; K: 0.11) on species
Identification (Table 4, 5, 6).
On both parasite detection and species identification, the agreement is lower in private clinics
(Detection A: 77.8%; Species Identification A: 37.2%), followed by health centers (Detection A:
84.14%; Species Identification A: 41.64%) and hospitals (Detection A: 86.7%; Species
Identification A: 48.1%) (Table 4).
Table 44: Overall performance of malaria microscopists in terms of parasite detection and species identification (n=237).
Expert reading % Agreement
Result
Parasite detection
Species identification
Negatives Parasite detection Species identification
All study
participants
reading
Pos 1578 508 47 A: 84.6%; K=0.6 A:43.8%; K: 0.11
Neg 318 1151 427
Total 1896 1659 474
Government Hospital staff
Pos 639 231 12 A:86.7 ; K: 0.65 A: 48.1; K:0.16
Neg 113 427 176
Health centre staff
Pos 820 246 31 A: 84.14; K:0.588
A: 41.64; K:0.08
Neg 164 615 215
Private facility staff
Pos 119 31 4 A: 77.8; K:0.478 A: 37.2 ;K:0.06
Neg 41 109 36
Total 1896 1659 474
Detailed Description of Performance by 2x2 Tables
Parasite Detection
Table 55:Parasite Detection as Positive or Negative on a 2x2 Table Format
Crosstab
Expert parasite detection Sensitivity
Specificity
Agreement % FP rate
% FN rate
Positive Negative Total
Participant parasite detection
Positive TP=1578 FP=47 1625 83.2% 2.9%
Negative FN=318 TN=427 745 90.1% 42.7%
Total 1896 474 2370 84.6%(K=0.6)
Where, TP: True Positive; TN: True Negative; FP: False Positive ; FN: False Negative; PPV: Positive Predictive Value; NPV: Negative Predictive Value
A. Percentage of slides in agreement in detection, i.e. percentage of positive slides correctly
identified and percentage of negative slides correctly identified:
% Agreement =TP+TN
TN+TP+FN+FPx100% =
1578+427
2370x100% = 84.6%; Cohen’s k: 0.6;
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This is a good grade in parasite detection (Range: 75%≤85%).
B. Sensitivity: Proportion of positive slides correctly read as positive Sensitivity =
TP
TP+FNX100% =
1578
1578+318X100% = 83.2%
C. Specificity: Proportion of negative slides correctly read as negative Specificity =
TN
TN+FPX100%
427
427+47X100% = 90.1%
D. False positive rate (% false positives)
False positivity rate =FP
TP+FPX100% =
47
1578+47x100% =2.9%
E. False negative rate (% false negatives)
False negativity rate =FN
TN+FNx100% =
318
427+318x100% = 42.7%
The accuracy of the differentiation of Plasmodium species
No or very slight agreement seen on differentiation of P. falciparum from other species (A: 28.41%;
K:0.29) (Table 6).
Table 66: The accuracy of the differentiation of Plasmodium species (2x2 table)
Crosstab Expert parasite species identification Agreement Cohen’s k
Single/mixed spp present
Negative Total K: 0.1099 Slight agreement
Participant species identification
Correct 508=A 47=B 555 43.8%
Incorrect 1151=C 427=D 1578
Total 1659 474 2133
Where, A is the number of slides reported as containing Plasmodium species as a single or a mixed infection by both readers; B is the number of slides reported as containing Plasmodium species only by the participant but not confirmed by the expert reader (incorrect species identification); C is the number of slides reported by the participant as not containing Plasmodium species, but Plasmodium species found to be present by the expert as a single or a mixed infection (incorrect species identification); and D is the number of positive slides reported as not containing Plasmodium species by both readers; k=kappa.
% Species identification agreement =A+D
A+B+C+Dx100% = 43.83%;
Where less than 65% is poor gradein species identification.
The accuracy of the differentiation of P. falciparum from other species
Table 77: The accuracy of the differentiation of P. falciparum from other species (2x2 table)
Crosstab Expert parasite species identification
Agreement Remark
Pf only/mixed Non-Pf Total
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Participant species identification
Pf only/mixed 275=A 345=B 620 Cohen’s k: -0.2985 No agreement
Non-Pf 673=C 129=D 802
Total 948 474 1422 28.4%
Where, A is the number of slides reported as containing P. falciparum (as a single or a mixed infection) by both readers; B is the number of slides reported as containing P. falciparum only by the participant but not confirmed by the expert reader (incorrect species identification); C is the number of slides reported by the participant as not containing P.
falciparum, but P. falciparum found to be present by the expert, as a single or a mixed infection (incorrect species
identification); and D is the number of positive slides reported as not containing P. falciparum by both readers; k=kappa
; Pf=Plasmodium falciparum
% Pf Species identification agreement =A + D
A + B + C + Dx100%
= 275+129
1422x100% = 28.41%; where less than 65% is poor grade.
No or slight agreement seen on differentiation of P. falciparum from other species (A:
28.41%; K:0.29).
Parasite counting system
Above 95% of study participants, 230 (97.0%), did not count or used plus system of parasite
estimation which is totally unacceptable per the current WHO guideline. Others 7(3.5%) used
parasite count against 8000 WBCs, 1(0.4%) participant from government hospital counted
parasites per parasite/µl against RBC; whereas the remaining study participants 29(12.18%)
completely did not count the parasites (Table 8).
Table 88: Parasite count system used by laboratory professionals
Facility type Total; n(%)
Zonal/district Hospital; n(%)
Health centre; n(%)
Private facility; n(%)
Parasite count lab tech used
Plus System 91(96.8) 119 (97.5) 20 (95.2) 230 (97.0)
Parasite/µl against WBC
2 (2.1)
3 (2.5)
1 (4.8)
6 (2.5)
Parasite/µl against RBC
1 (1.1)
0
0
1 (0.5)
Total 94(100) 122(100) 21 (100) 237 (100)
Performance of malaria microscopists on species identification with different parasite
densities
In the current study, the accuracy of parasite species identification was low in high parasite density
than low density slides. In the case of P. falciparum, accuracy of identification more lower on high
parasite density slides (correct reading: 23.6%) than at low density slides (correct reading: 57.8%).
Similarly in P.vivax also accuracy of identification more lower on high parasite density slides
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(correct: 13.9%) than at low density slides (correct: 40.5%). Yet the same is true in Pf/Pv mixed
slides where accuracy of species identification was lower at high density (13.9%) than low density
slides (20.7%). Generally, the participants performance was a little bit good in low density P.
falciparum species identification (57.8%), followed by low density P.vivax (40.5%). Whereas in
other parasite densities, below 21% of slides were read correct by the participants on species
identification. Participants skill in Borella identification (59.7% slides read correct) better than
Plasmodium species (Table 9).
Table 99: Performance of malaria microscopists on species identification with different parasite densities (n=237).
Participant Species identification
Pf low parasite density,
Pf high parasite density,
Pv low parasite density,
Pv high parasite density,
Mixed Pf+Pv low density,
Mixed Pf+Pv high density,
Borella,
n(%) n(%) n(%) n(%) n(%) n(%) n(%)
Correct 137(57.8) 56(23.6) 96(40.5) 33 (13.9) 49(20.7) 33(13.9) 141(59.7)
Incorrect 100(42.2) 181(76.4) 141(59.5) 204(86.1) 188(79.3) 204(86.1) 95(40.3)
Total 237(100) 237(100) 237(100) 237(100) 237(100) 237(100) 236(100)
Where: Pf is Plasmodium falciparum, Pv is Plasmodium vivax
Overall performance of malaria microscopists against sociodemography
Better performance was seen by participants having Master degree than bachelor degree and
Diploma certificate. Graduates from government or public universities/colleges had better
performance than graduates of private colleges. Participants skill also differs based on the
experience years: the higher the service year the higher is participants capacity to detect and
identify parasites (Table 10).
Table 1010: Overall performance of malaria microscopists against sociodemography
Variables
Degree
Result
Expert reading
Agreement b/n participant & expert
Parasite Detection
Species Identification
Negative
Parasite Detection
Species Identification
Level of Education
Diploma Pos 1060 619 40 A: 82.96% K:0.57
A: 61.93% K:0.28 Neg 236 515 284
BSc Pos 510 363 9 A: 86.8% K:0.66
A: 74.7% K=0.46 Neg 90 162 141
MSc Pos 8 5 0 A: 100% K:1
A: 70% K: 0.39 Neg 0 3 2
Type of college
Government
Pos 1459 926 43 A: 85% K:0.62
A: 67.4% K:0.35 Neg 277 593 391
Private Pos 119 61 6 A: 73.8% K:0.41
A: 51.3% K:0.16 Neg 49 86 36
< 2 yrs Pos 256 156 18 A: 81.0256% A: 61.5384%
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Work Experience
Neg 56 117 60 k: 0.49 K: 0.23
2-5 yrs Pos 441 253 12 A: 85% k: 0.61
A: 62.79% k: 0.29 Neg 87 209 120
>5 yrs Pos 719 464 16 A:85.09% K: 0.62
A: 68.31% K:0.37 Neg 145 292 200
In-service Training
Trained Pos 946 614 28 A: 85.57% K: 0.62
A:71.32 K:0.44 Neg 174 366 252
Not trained Pos 610 357 19 A: 82.21 K:0.56
A: 61.754 K:0.28 Neg 150 308 171
PART 2: LABORATORY REAGENTS/SUPPLIES, EQUIPMENTS &
DOCUMENTATION
Generanl Laboratory or facility Information
This assessment was conducted in 17 district hospitals, 71 health centers and 18 private health
facilities; giving a total of 106 health facilities. Of the 18 private clinics, only 10(55.6%) had license&
registration certificate. Of the facilities, 92.4% (98/106) use only light microscopy, 3.8%(4/106) use
only malaria RDTs and 3.8%(4/106) use both microscopy and RDT to detect malaria. Daily malaria
workload was assessed by the laboratories malaria slide examination. Among the health facilities,
29(28.7%) facilities examined less than five slides per day, 29(28.7%) examined 5-10 slides/day
and 43(42.6%) facilities were examining more than 10 slides/day. Accessible and appropriate
storage of Giemsa was reported by 83.3%(14/17) hospitals, 87.3%(62/71) Health Centers &
83.3%%(15/18) private clinics. Supervision to the health facilities was done by regional and national
reference laboratories (Ethiopian Public Health Institute). Out of the total health facilities, 56(54.9%)
were supervised within one year prior to study period (Table 11).
Table 1111: General laboratory information I.
Types of health facility, n(%) Total 17(16) 71(61) 18(17) 106(100)
Registered and licensed private laboratory
Yes NA NA 10(55.6) 10(55.6)
No NA NA 8(44.4) 8(44.4)
Supervision from regional or national laboratories within a year
Yes 12(80) 37(52.9) 7(41.2) 56(54.9)
No 3(20) 33(47.1) 10(58.8) 46(45.1)
Method of diagnosis for malaria Microscope 16(94.1) 66(93.0) 16(88.9) 98(92.4)
RDT 1(5.9) 2(2.8) 1(5.6) 4(3.8)
Both 0 3(4.2) 1(5.5) 4(3.8)
Daily malaria slides examined Less than 5 1(6.2) 22(31.9) 6(37.5) 29(28.7)
From 5-10 2(12.5) 21(30.4) 6(37.5) 29(28.7)
More than 10 13(81.2) 26(37.7) 4(25) 43(42.6)
Accessible & appropriate storage of Giemsa solution
Yes 14(83.3) 62(87.3) 15(83.3) 91(85.8)
No 3(16.7) 9(12.7) 3(16.7) 15(14.2)
Giemsa stock taken from Regional lab 5(31.2) 25(35.2) 0 30(28.8)
Facility self 10(62.5) 42(59.2) 12(70.6) 64(61.5)
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Partners 0 2(2.8) 0 2(1.9)
EPHI & Partner 1(6.2) 2(2.8) 5(299.4) 8(7.7)
Functional microscope was reported available in all hospitals, in 67(94.4%) of health centers and
13(81.2%) of private clinics during the survey. In this study, 4(25%) of hospitals, 19(26.8%) of
health centers and 7(43.8%) of private hospitals/clinics perform only thick blood smear for malaria
examination. Above 95% of health facilities use the plus system of parasite density estimation.
Regular training program for microscopists is available in 12(12.9%) facilities while the remaining
have none. Out of the total health facilities, 50(49.5%) were participating in any of the external
quality assurance(EQA) programs (Table 12).
Table 1212: General laboratory information II.
Variables Response Category
District Hospital
Health centre
Private hospital/clinic
Total
Functional microscope available
Yes 16(100) 67(94.4) 13(81.2) 96(93.2)
No 0 4(5.6) 3(18.8) 7(6.8)
Malaria blood smear preparation
Thin only 0 1(1.4) 0 1(1)
Thick only 4(25) 19(26.8) 7(43.8) 30(29.1)
Thick and thin 12(75) 51(71.8) 9(65.2) 72(69.9)
Perform parasite count Yes 10(62.5) 24(35.3) 8(50) 42(42)
No 6(37.5) 44(64.7) 8(50) 58(58)
Parasite count types used 1+, 2+, 3+, 4+ 11(100) 25(92.6) 11(100) 47(95.9)
Parasite/µl/WBC 0 1(3.7) 0 1(2)
Parasite/µl/RBC 0 1(3.7) 0 1(2)
Regular training program for microscopists available
Yes 3(23.1) 9(13.6) 0 12(12.9)
No 10(76.9) 57(86.4) 14(100) 81(87.1)
Participate in any EQA programs
Yes 9(52.9) 37(52.1) 4(23.5) 50(49.5)
No 6(47.1) 32(47.9) 13(76.5) 51(50.5)
Laboratory Documentation
No standard laboratory request form was observed in 6(37.55) of hospitals, 44(63.8%) of health
centers and 11(64.7%) private clinics. Results were recorded legibly in logbooks of 87.5%(14)
hospitals, 87.1%(61) health centers, and 87.2%(75) private clinics. Standard operating procedures
were absent at 2(12.5%) hospitals, 30(42.9%) health centers and 12(70.6%) private clinics.
Technical manuals and lab bench aids were observed in 56.2%(9) hospitals, 57.1% (40) health
centers and 35.3%(6) private clinics. Internal quality control log sheet was seen unavailable in
3(18.8%) hospitals, 39(55.7%) health centers and 15(88.2%) private clinics (Table 13).
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Table 1313: Laboratory Guidelines, SOPs and Manuals
Variables Response Category
District Hospital
Health Centre
Private Hospital/Clinic
Total
Availability of standard laboratory request form
Yes
10(62.5)
25(36.2)
6(35.3)
41(40.2)
No 6(37.5) 44(63.8) 11(64.7) 61(59.8)
Organized result recording in logbooks
Yes 14(87.5) 61(87.1) 10(58.8) 85(82.5)
No 2(12.5) 9(12.9) 7(41.2) 18(17.5)
SOPs availability in Laboratory
Yes 14(87.5) 40(57.1) 5(29.4) 59(57.3)
No 2(12.5) 30(42.9) 12(70.6) 44(42.7)
Technical manuals and bench aids in the laboratory
Yes 9(56.2) 40(57.1) 6(35.3) 55(53.4)
No 7(43.8) 30(42.9) 11(64.7) 48(46.6)
Internal quality control log sheet available
Yes 13(81.2) 31(44.3) 2(11.8) 46(44.7)
No 3(18.8) 39(55.7) 15(88.2) 57(55.3)
Maintenance logbook for microscope
Yes 14(87.5) 41(59.4) 4(23.5) 59(57.8)
No 2(12.5) 28(40.6) 13(76.5) 43(42.2)
Laboratory Procedures
In 11(84.6%) hospitals, 25(35.7%) health centers & 4(26.7%) private clinics, the laboratories
comply fully with the national quality assurance guidelines. Internal quality control was not being
performed in 6(37.5%) hospitals, in 42(61.8%) health centers, 13(86.7%) private clinics. Buffered
distilled water used to dilute Giemsa stain in only 17(16.7%) facilities where as 87(83.3%) facilities
were using tap water (Table 14).
Table 1414: Laboratory Procedures
Variables Response Category
District Hospital
Health centre
Private hospital/clinic
Total
Internal quality control performed
Yes 10(62.5) 26(38.2) 2(13.3) 38(38.4)
No 6(37.5) 42(61.8) 13(86.7) 61(61.6)
Buffered Dist water used to dilute Giemsa stain
Yes 1(6.2) 16(23.2) 0 17(16.7)
No 15(93.8) 53(76.8) 17(100) 87(83.3)
Laboratory fully comply with the national quality assurance guideline
Yes 11(84.6) 25(35.7) 4(26.7) 40(40.8)
No 2(15.4) 45(64.3) 11(73.3) 58(59.2)
Formal protocol for analyzing internal quality control
Yes 10(71.4) 18(25.7) 4(25.0) 32(32)
No 4(28.6) 52(74.3) 12(75.0) 68(68)
Laboratory set up
Hospitals have good bench space, sink, washing and staining area, ventilation and lab space, and
disposal of waste materials per national guideline compared to health centers and private clinics.
Storage space for supplies & materials was observed poor in 2(13.3%) hospitals, 24(33.8%) health
15 | P a g e
centers and 8(47.1%) private clinics. Health centers and private clinics have problems in electric
power supply for uninterrupted service and waste disposal system (Table 15)
Table 1515: Laboratory set up and working environment
Variables Response Category
District Hospital
Health centre
Private hospital/clinic Total
Bench space for microscope, reg book
Good
15(100)
60(84.5)
13(76.5)
88(85.4)
Poor 0 11(15.5) 4(23.5) 15(14.6)
Sink, washing and staining area
Good 15(100) 32(45.1) 7(43.8) 54(52.9)
Poor 0 39(54.9) 9(56.2) 48(47.1)
Ventilation and lab space Good 15(100) 66(93) 13(76.5) 94(91.3)
Poor 0 5(7) 4(23.5) 9(8.7)
Storage space for supplies & materials
Good 13(86.7) 47(66.2) 9(52.9) 69(67)
Poor 2(13.3) 24(33.8) 8(47.1) 34(33)
Using personal protective equipments
Yes 13(86.7) 52(73.2) 13(76.5) 78(75.7)
No 2(13.3) 19(26.8) 4(23.5) 25(24.3)
Uninterrupted power supply
Yes 14(93.3) 57(80.3) 13(76.5) 84(81.6)
No 1(6.7) 14(19.7) 4(23.5) 19(18.4)
Disposal of waste materials per national guideline
Yes 15(100) 46(65.7) 9(52.9) 70(68.6)
No 0 24(34.3) 8(47.1) 32(31.4)
Laboratory Supplies and Equipment over the last six months prior to data collection I
High quality laboratory equipment and laboratory supplies are very important to provide accurate
and reliable laboratory results for customers. All participant laboratories were assessed for their
laboratory supplies and equipment status in terms of quality and quantity. From a total of 86
governmental health facilities, 84(97.7%) had binocular microscope with oil immersion (x100)
objective while the other 2(2.3%0 of governmental facilities had no binocular microscope with oil
immersion (x100) objective. These may be due to lack of using microscope totally at health
facilities, or the microscope was not functional to provide microscopy services. From study
participant health facilities; 63.5% of governmental facilities and 52.9% of private health facilities
were not conducting regular microscopy services. This may be due to many reasons such as lack
of service agreement for microscope at national level or laboratory personnel were not trained on
microscope service or lack of commitment from staffs to do regular services are some of the
reasons (Table 16).
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Table 1616: Laboratory Supplies and Equipment over the last six months prior to data collection I.
Supplies and Equipment
Response Category
Government Health Facilities (n%)
Private Hospital/Clinic (n%)
Total (n%) District
Hospitals Health center
Total
Microscope binocular
with x100 objective
Yes 14(93.3%) 70(98.6%) 84(97.7) 16(100.0%) 100(98.0%
)
No 1(6.7) 1(1.4) 2(2.3) 0 2(2)
Regular microscope
service
Yes 6(42.9) 25(35.2) 31(36.5) 8(47.1) 39(38.2)
No 8(57.1) 46(64.8) 54(63.5) 9(52.9) 63(61.8)
Availability of spare
bulbs for microscope
Yes 9(69.2) 18(25.2) 27(32.5) 5(29.4) 32(32)
No 4(30.8) 52(74.3) 56(67.5) 12(70.6) 68(68)
Availability of quality
and cleaned
microscope slides
Yes 13(86.7) 62(87.3) 75(87.2) 12(70.6) 87(84.5)
No 2(13.3) 9(12.7) 11(12.8) 5(29.4) 16(15.5)
Re-using microscope
slides
Yes 6(40) 18(25.4) 24(27.9) 9(52.9) 33(32)
No 9(60) 53(74.6) 62(72.1) 8(47.1) 70(68)
Availability of all
required reagents
Yes 14(93.3) 59(84.3) 73(85.9) 7(41.2) 80(78.4)
No 1(6.7) 11(15.7) 12(14.1) 10(58.8) 22(21.6)
Storage of Staining
solutions per the
manufacturers guide
Yes 13(92.9) 53(77.9) 66(80.5) 13(81.2) 79(80.6)
No 1(7.1) 15(22.1) 16(19.5) 3(18.8) 19(19.4)
Most of the supplies such as alcohol, cotton, lancets, Giemsa stain, disposables gloves, lens
cleaning solution, sharps containers, staining rack, drying rack were available sufficiently in most
governmental and private health facilities; whereas these supplies were insufficient or not available
at all in some health facilities. The reason for insufficient quantity or unavailability at all at some
health facilities may be due to poor inventory system of the laboratories, the lack of finance to
purchase the supplies on time, they may be donor dependent so that they may encounter shortage
of supplies when the donor terminate the support, it may be due to lack of commitment from staffs
to forecast the supplies on time and lack of follow up on the requested supplies, the governmental
organizations which are responsible for supply distribution may not distribute supplies on time, or
the expiry date of the supplies may be short (Table 17).
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Table 1717: Laboratory Supplies and Equipment over the last six months prior to data collection
Supplies and Equipment
Response Category
Government Health Facilities (n%)
Private Clinic (n%)
Total (n%) District
Hospitals Health center
Total
Alcohol and cotton for cleaning skin prior to blood collection
No 0 3(4.3) 3(3.6) 1(5.9) 4(4)
Sufficient 11(84.6) 57(81.4) 68(81.9) 13(76.5) 81(81)
Insufficient 2(15.4) 10(14.3) 12(14.5) 3(17.6) 15(15)
Lancets No 0 1(1.4) 1(1.2) 1(5.9) 1(2)
Sufficient 13(100) 68(95.8) 81(96.4) 15(88.2) 96(95)
Insufficient 0 2(2.8) 2(2.4) 1(5.9) 3(3)
Giemsa stain No 1((7.1) 5(7) 6(7) 0 6(5.9)
Sufficient 12(85.7) 59(83.1) 71(83.5) 16(94.1) 87(85.3)
Insufficient 1(7.1) 7(9.9) 8(9.4) 1(5.9) 9(8.8)
Disposables Gloves No 1(7.1) 10(14.1) 11(13) 0 11(10.8)
Sufficient 11(78.6) 47(66.2) 58(68.2) 13(76.5) 71(69.6)
Insufficient 2(14.3) 14(19.7) 16(18.8) 4(23.5) 20(19.6)
Lens cleaning solution No 7(53.8) 41(57.7) 48(57.1) 13(81.2) 61(61)
Sufficient 4(30.8) 19(26.8) 23(27.4) 2(12.5) 25(25)
Insufficient 2(15.4) 11(15.5) 13(15.5) 1(6.2) 14(14)
Sharps containers No 0 1(1.4) 1(1.2) 3(17.6) 4(3.9)
Sufficient 13(92.9) 61(85.9) 74(87) 13(76.5) 87(85.3)
Insufficient 1(7.1) 9(12.7) 10(11.8) 1(5.9) 11(10.8)
Staining Rack No 0 12((16.9) 12(14.1) 5(29.4) 17(16.7)
Sufficient 13(92.9) 51(71.8) 64(75.3) 7(41.2) 71(69.6)
Insufficient 1(7.1) 8(11.3) 9(10.6) 5(29.4) 14(13.7)
Drying rack No 3(21.4) 18(25.4) 21(24.7) 8(47.1) 29(28.4)
Sufficient 10(71.4) 47(66.2) 57(67) 9(52.9) 66(64.7)
Insufficient 1(7.1) 6(8.5) 7(8.3) 0 7(6.9)
CONCLUSION
Most of the malaria microscopists in the current study achieved good grade in parasite detection
and poor grade in parasite species identification. The findings show the mcroscopists are yet “In-
Training” level despite certain works exerted to enhance the quality of microscopy and laboratory
capacity in the country. The findings also showed gaps in laboratory set up, documentation and
Giemsa solution mainly at health centers and private clinics than district hospitals. The low skill of
malaria microscopists harmonized with the poor laboratory set up, documentation, and supplies in
the current study places a great obstacle in front of malaria elimination path. Therefore,
comprehensive In-service training and certifying professionals led by the WHO country office &
Ministry of Health should be commenced to have gold standard malaria microscopy service.
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RECOMMENDATIONS
The FMoH/EPHI in collaboration with partners should do the following to have quality malaria
microscopy:
o Conduct regular on-site supervision.
o Check staff competence.
o Check reagent quality and the microscope.
o Consider intensive on-the-job training to remedy weaknesses.
o Check reagent quality and the microscope.
o Conduct regular follow-up for corrective action.
o Try to fulfill the shortages in reagents and equipments in the laboratory
o Prepare new manuals, bench aids and SOPs in numbers sufficient to address the
laboratories in the countries.
DISSEMINATION OF RESULTS
The findings of this research will be submitted to the EPHI/FMOH and the IFCC Foundation for
Emerging Nations (FEN), Geneva, Switzerland. It will also be disseminated to all stakeholders,
public and concerned bodies through presentation in different professional association meetings
and conferences in and outside the country. The final paper will be submitted to international peer-
reviewed journals for publication.
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ANNEXES
ANNEX 1: GENERAL QUESTIONS FOR MALARIA MICROSCOPISTS
Facility Name: ___________________________________District_________________________ Zone____________________________________Region______________________________ Participant Name: ________________________ID:___________ Date: _____________ Profession: Lab technician Lab technologist Phone: _____________________
No Questions Response Category Remark
1. Age in Years _______________
2. Sex 1. Male 2. Female
3. When did you Graduate? 1. Less than 1yr 2. 1-2 years 3. >2 years (_________yrs)
4. Which college did you graduate from? 1. Government 2. Private 3. Other_______
5. What is your qualification? 1. Diploma 2. Bachelor degree 3. Master’s degree 4. other_____________
6. Field of study/s:
7. What course did you take in your college concerning malaria diagnosis?
1. Theoretical only 2. Theoretical & Practical
8. How long have you worked as malaria microscopist?
_______________
9. Have you taken In-service training on malaria microscopy?
1. Yes 2. No
10. If yes, when and how many times? 1. Once: ______(date) 2. 2 times:______,_______ 3. 3-
times______,_____,______ 4. More:
_______,______________
11. When was your last training? ______________________________
12. Who did give you training? 1. Government:__________________________________
2. NGO:__________________
13. Do you diagnose malaria detection? 1. Yes 2. No
14. Do you identify malaria species? 1. Yes 2. No
15. Do you identify all parasite life stages? 1. Yes 2. No
16. Do you perform parasitaemia count? 1. Yes 2. no
17. If yes, which count do you use? 1. +, ++, +++, ++++
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2. Parasite per micro liter/ WBC
3. Parasite per micro liter/ RBC
RESULT REPORTING FORM FOR LABORATORY PROFESSIONALS (PROFICIENCY ASSESSMENT)
Participant Name: ________________________ID: ____________ Date: _________
Lab technician Lab technologist Phone:_________________________
Slide ID
Result
Remark
Negative
Positive
Species Stage Parasite Load
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Write the species as Pf, Po, Pv, Pm; Negative as Neg.
Signature of the lab technicians/technologist___________________________ Date: __________
Data collector name_____________________________ Signature _________Date: __________
COMPETENCY ASSESSMENT
Reference slides provided by the supervisor and examined by the laboratory
Microscopists
1 2 3 4 5
No. of slides read
Parasite detection agreement (%)
False positives (%)
False negatives (%)
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Species identification agreement (%)
Performance (review of slides), crosschecking
No. of slides cross-checked by validator -----
Parasite detection agreement (%)
False positives (%)
False negatives (%)
No. of true positives
Species identification agreement (%)
Parasite density agreement (%)
Poorly prepared thick films (consider size, shape and volume of blood) (%)
Poorly prepared thin films (consider size, shape and volume of blood) (%)
Slides poorly stained (%)
Slides containing stain precipitate or artifacts (%)
Slides auto-fixed (%)
Basis for determining competence levels in a national competence assessment
Competence level
Parasite Detection (%)
Species Identification (%)
Parasite count(within 25% of true count)
Preparation of thick and thin blood films
Excellent 90–100 90–100 50–100 90–100
Very good 80–89 80–89 40–49 80–89
Good 70–79 70–79 30–39 70–79
Fair/poor 0–69 0–69 0–29 0–69
Minimum competence levels for peripheral-level microscopists
Competence Result
Sensitivity: Proportion of positive slides correctly read as positive 90%
Specificity: Proportion of negative slides correctly read as negative 80%
Accuracy of reporting P. falciparum when present 95%
ANNEX 2: FACILITY INFORMATION QUESTIONNAIRE
Form for assessment of malaria microscopy laboratories
Name of laboratory or facility: Date of visit
(dd/mm/yyyy):___/___/_______
Type of facility: Rural clinic/HC District hospital Zonal hospital
Private hospital Private Laboratory Other (specify)_______
Physical address of laboratory:
District, city, town: Zone:
Telephone: Fax: E-mail:
Name of head of department or director of laboratory:
Name of head of facility:
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Names of microscopist interviewed: Education & degree 1._________________________________________ _______________________________________ 2.__________________________________________ ________________________________________ 3._________________________________________ ________________________________________ 4.__________________________________________ ________________________________________ 5.__________________________________________ ________________________________________
Name of interviewer:
General malaria diagnostic service
Questions Response Category
Remark
Is the lab registered and licensed to practice microscopy (for private laboratory)?
1. Yes 2. No
Is there any supervision from regional or national laboratories?
1. Yes 2. No
Does your lab participate in EQA programs? 1. yes 2. no
Which do you use, microscope or RDT? 1. Microscope 2. RDT 3. other_________
Is the lab provide routine malaria smear microscopy service
1. yes 2. no
How many malaria slides do you examine daily?
1. Less than 5 2. From 5-10 3. More than 10, if so______
Is the staining solution are accessible and stored in appropriate place
1. Yes 2. No
Where do you get the Giemsa stock from? 1. Regional lab 2. Facility purchasing 3. EPHI 4. NGOs: ------------------------------------------------------------------- 5. Other:-------------------------------------
Do you have properly functional microscope? 1. Yes 2. No
Which malaria blood smear do you use? 1. Thin film only 2. Thick film only
3. Thick and thin film
Do you perform parasitaemia count? 1. Yes 2. No
If yes, which methods do you use 1. +, ++, +++, ++++ 2. Parasite/µl/WBC 3. Parasite/µl/RBC
Is there a regular training program for microscopists?
1. Yes 2. No
Documentation
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Questions Response category Remark
Are pathology request forms available? 1. Yes 2. No
Are results recorded in an organized and legible manner in logbooks?
1. Yes 2. No
Are approved SOPs available in the laboratory? 1. Yes 2. No
Are technical manuals and bench aids available in the laboratory?
1. Yes 2. No
Are internal QC log sheets available? 1. Yes 2. No
Are maintenance logbooks for microscopes and pH meters available?
1. Yes 2. No
Laboratory Procedures
a) Blood film preparation
Yes No Remarks
Are SOPs available for blood film preparation?
Are both thick and thin films prepared?
Are blood films labeled appropriately?
Is the quality of prepared blood films monitored?
Are unstained slides protected from insects and Auto- fixation?
b) Blood film staining
Questions Response category
Remark
Are SOPs available for blood film staining? 1. Yes 2. No
Are recommended reagent preparation procedures followed?
1. Yes 2. No
Is internal QC performed regularly with known positive and negative slides during staining?
1. Yes 2. No
What is the staining technique used? 1. Giemsa stain 2. Other(specify)___________
Is buffered distilled water pH 7.2 ± 0.2 used to dilute the Giemsa stain?
1. Yes 2. No
Is the Giemsa working stain solution freshly prepared before each staining (within 4 hr)?
1. Yes 2. No
c) Blood film examination
Yes No Remarks
Are SOPs available for examination of blood films?
Do microscopists routinely report the presence or absence of parasites, species and density?
Do microscopists report parasite density in the WHO-recommended way (parasites/µL)?
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Does the workload allow the recommended reading time (at least 10 min) per slide?
Are examined slides stored and archived properly?
Fill out dashes
Average number of slides read per month
No. of slides read per day
Average no. of slides read per day per microscopist
No. of slides archived or assessed by validator
Quality assurance
Yes No Remarks
Does the laboratory comply fully with the national QA and QC guidelines?
Is there a formal protocol for analyzing internal QC results and taking corrective action if the results are not satisfactory?
Does the laboratory or microscopists regularly participate in a proficiency testing scheme or other form of external QA?
Is the performance of the laboratory or microscopists in the proficiency testing scheme or other form of external quality assessment satisfactory?
Does the laboratory have procedures to address poor performance in proficiency testing or other forms of external quality assessment?
Laboratory set-up and environment
Good Poor Remarks
Bench space
Sink, washing area, staining area
Access to clean water supply
Natural lighting
Power source
Ventilation
Storage space for supplies and materials
Storage space for unstained and examined slides
Secure storage space for confidentiality of patient results
Good: at least 2-bench space, chair for clients and for lab professionals, windows designed for ventilation, store etc
Bio-safety
Yes No Remarks
Laboratory staff wear protective laboratory coats and gowns and safety glasses
No pockets, with tight cuffs
Staff wear gloves when collecting and handling blood samples
Hand-washing facilities with soap (or similar) available
Power supply for the microscope(s) and laboratory lighting in good condition and safe
Containers for dry waste
Containers for infectious materials
Puncture-resistant container for sharps and blood slides
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Disposal of waste materials as per national guidelines
Equipment and reagents
Microscope
Yes No Remarks
The microscope(s) is binocular with oil immersion x100 objective
The microscope lamp(s) has sufficient power to provide good illumination when the condenser aperture is set at the correct setting for the x100 objective
Blood films can be brought into sharpfocus at x100 oil immersion magnification.
The stage movement mechanism is precise and stable.
The microscope is placed on a stable bench, with adequate working space and away from staining areas and vibration producing equipment such as centrifuges
The microscope(s) is regularly serviced.
The microscope(s) is cleaned and protected with a cover after use.
Xylene is used to clean the microscope(s), objectives or eye pieces Xylene is carcinogenic and should not be used.
Spare microscope bulbs are available.
Microscopic slides
Yes No Remark
Microscope slides are of good quality and are thoroughly cleaned before use.
Microscope slides do not have scratches or surface aberrations.
Microscope slides do not give a blue background color after staining.
Microscope slides do not have fungal contamination.
Microscope slides that have been damaged by fungus are discarded and not used again.
In areas with high humidity, microscope slides are protected against fungal contamination.
Microscope slides are re-used.
Staining reagents
Yes No Remark
All required staining reagents are available.
All staining reagents are within the recommended expiry date.
Staining solutions are stored as per the manufacturer’s recommendations.
SOPs are available for preparation of working stain solutions.
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Internal QC is performed for each batch of working stain solution prepared and each batch of commercially prepared stain opened for use.
Commercial stain solutions do not contain excessive stain precipitate.
The cap of the reagent bottle is always tightly sealed except when stain is being removed for use.
Stain is always removed from the reagent bottle with a clean pipette or similar.
Water is never added to the stock stain solution.
Unused stain is never returned to the stock bottle.
All required staining reagents are available.
General laboratory supplies
Presence Remarks
No Sufficient Insufficient
Alcohol and cotton (or similar) for cleaning skin prior to blood collection
Lancets
Methanol
Giemsa stain
Buffer salts or buffer tablets
pH meter accurate to two decimal places
pH calibration solutions
Staining jar
Microscope light bulbs
Spreader (for making blood films)
Laboratory gowns
Safety glasses including over-spectacles type
Gloves, disposable
Lens cleaning solution
Marker pens
Sharps containers
Needles and syringes
Vacuum vein puncture supplies
Pencils, grease, red, glass-writing
Slide labels
Cover slips
Mounting medium
Tourniquet
Wound cover strips
Staining rack
Drying rack
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Graduated cylinders of the correct size
Wash bottles
Timers, sufficient number for staining for each microscopist
Immersion oil of acceptable viscosity (not too thick and not too thin)
Tally counters, sufficient number for the number of staff
Lens paper
Slide boxes for storage
For laboratories in which stain is prepared from powder: sufficient glycerol, methanol, powder, beakers, measuring cylinders, filter paper, funnels, stirringrods, scales, spatulas and storage bottles
Performance indicators
Monitoring of: Yes No Remarks
Total number of slides examined
Total number of positive slides, stratified by species
Consumption of commodities
Monthly stock-outs of microscopy reagents
Turnaround time for microscopy results
General findings and recommendations: ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Supervisor or auditor’s comments: ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Accomplished by: Name of auditor________________________________________________________ Signature of auditor_____________________________________________________ Date: -----------------------------------------------------
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ANNEX 3: OPERATIONAL DEFINITIONS
Malaria Microscopist: is a professional laboratory person who uses microscope to read blood films to aid
or confirm the diagnosis of malaria and report their findings.
Performance: is the skill of malaria microscopists for doing an accurate examination and reporting of a
malaria blood film.
Agreement: is a combination of sensitivity and specificity that describes the number of correct answers given
or the amount of agreement between the expert reader and the participant's answers. Therefore, both true
negatives and true positives are counted toward this measurement.
Sensitivity: is the probability of producing a true positive result when used in an infected population as
compared to an expert reader.
Specificity: is the probability of producing a true negative result when used on an uninfected population as
determined by an expert reader.
In-training: this is the lowest WHO-classification level in the performance of malaria microscopists.
Personnel with this performance need training to fill their gap in providing malaria microscopy services up to
getting appropriate training.
Expert: WHO-certified level-1 malaria microscopists who have special skill or knowledge in diagnosing and
confirming the blood film results.
ASSURANCE OF THE PRINCIPAL INVESTIGATOR:
I, the undersigned agree to accept responsibilities for the scientific, ethical, and technical conduct of the research project and for provision of progress reports as per term, submission of technical reports and scientific publications if the project is approved as a result of this application.
Name: ____________________________________________________________________
Signature_________________ Date______________________
SIGNATURE OF CO-INVESTIGATORS
Name Specific Responsibility Signature
1. ___________________ _____________________ _______________________________
2. ___________________ _____________________ _______________________________
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3___________________ _____________________ _______________________________
4. ___________________ _____________________ _______________________________
5. ___________________ _____________________ _______________________________
6. ___________________ _____________________ _______________________________
7. ___________________ _____________________ _______________________________
8. ___________________ _____________________ _______________________________
COMMENT AND CONCURRENCE OF THE RESPONSIBLE HEAD FOR PRINCIPAL INVESTIGATOR.
___________________________________________________________________
___________________________________________________________________
Name__________________________Signature______________Date___________